Case

6yr boy is brought to the OPD with

complaints of recurrent painful swelling
of the Lt Knee joint since 2yr of age. He
also has a history of prolonged bleeding
from cut sites.

One maternal uncle of the child died due

to prolonged bleeding following a minor
surgery.

O/E, No petechiae/purpura.
Lt Knee joint swollen, tender
Hemophilia and
Coagulation
Disorders

Dr Nishant Verma
 Hemostatic Mechanism
 Platelet adhesion
 Platelet aggregation
 Clot formation
 Clot stabilization
 Limitation of clotting to the site of
injury by regulatory anticoagulants,
and
 Re-establishment of vascular patency
through fibrinolysis and vascular
healing
 von Willebrand‘s
Factor (vWF)
binds to
subendothelial
collagen.

BERNARD- SOULIER SYNDROME

Conformational changes occur in

vWF allow it to bind to the GP
Ib/IX receptor on platelets,
causing adhesion
 Fibrinogen acts as
The GP IIb/IIIa
a glue binding
receptor complex
platelets together.
changes conformation
allowing binding of
fibrinogen.

GLANZMANN’s Thrombasthenia
 Clotting Factors
I Fibrinogen
II Prothrombin
V Labile factor, proaccelerin
VII Stable factor or proconvertin
VIII Antihemophilic factor (AHF)
IX Christmas factor
X Stuart-Power factor
XI Plasma thromboplastin antecedent
XII Hageman factor
XIII Fibrin Stabilizing Factor
 Waterfall cascade:
s ic
tr in y
In hwa I,

Ex
t

tr
I
pa tor X in andI ,

in
si
c
Fa llikre tor X r

Ti fac

c
ss to

pa
k a fac cto

ue r
e , fa

th
pr K ,

w
W r IX

f a V II
M

ay
II

ct
H cto I
V

or
fa

,
Factor X Factor Xa

Common Prothrombin Thrombin

Pathway

Fibrinogen Fibrin
HEMOPHILIA
Overview of fibrinolytic mechanism
von Willebrand Factor
Classification of bleeding disorders
• Primary Hemostatic defect
– Platelet disorder
• Congenital
• Acquired
– Von Willebrand Disease
• Coagulation Disorders (Clotting factor deficiency)
– Acquired
– Inherited
• Vascular
 Classification of bleeding disorders
Clinical characteristic Primary Hemostatic Defect Coagulation Disorder
Site of bleeding Skin, mucous membrane Soft tissues, muscles, joints
Bleeding after minor cuts Yes No
Petechiae Yes No
Ecchymosis Small, superficial Larger, deeper
Hemarthrosis Rare Common
Bleeding after trauma/surgery Immediate Delayed
Example Platelet defect, vWD Hemophilia

Source: Nathan and Oski’s Hematology of Infancy and Childhood. 7 th Edition, Pg 1450
Clinical Approach to bleeding disorders

History

Physical Examination

Laboratory Evaluation
 Clinical Approach to bleeding disorders
History
Nature of bleeding-
- Immediate vs delayed
- Superficial vs deep
- Surgical / dental history
Family H/O bleeding-
- Others involved ?
- Males only? (x-linked)
- Consecutive generations
Medication history-
-NSAID, Heparin (patients with central lines)
Others- Liver / renal disease
 Clinical Approach to bleeding disorders

Physical Examination
Bruises-
- Number
- Location
- Site
Petechiae
Joint bleeding
Other Physical findings-
- Jaundice
- Skeletal deformity
- Hepatosplenomegaly
Clinical Approach to bleeding disorders
Screening Laboratory Evaluation

• Platelet count / morphology

• Coagulation profile
– Prothrombin time (PT)
– Activated partial thromboplastin time (APTT)
– Bleeding time (BT)
 BT / CT
• Bleeding time • Clotting time
– 3-9 min – 3-6 min
 Coagulation profile

• Sample collection

– Citrated tube

– Gently mixed

– Immediate transport
 Coagulation profile
• PT
– Method
– Normal – 10-11s
– INR = (Patient PT/Control PT)ISI
– Isolated  PT
• APTT
– Method
– Normal – 26-35s
– Isolated  APTT
–  PT +  APTT TT

• TT
 Advanced tests

• Factor assays

• Testing for vWD

• Platelet function analyzer (PFA 100)

Classification of bleeding disorders
• Primary Hemostatic defect
– Platelet disorder
• Congenital
• Acquired
– Von Willebrand Disease
• Coagulation Disorders (Clotting factor deficiency)
– Acquired
– Inherited
• Vascular
 Coagulation Disorders: Acquired
• Vitamin K deficiency

• Liver disease

• Accelerated destruction of coagulation factors

• Inhibitors of coagulation

• Miscellaneous
 Vitamin K Dependent Proteins
Dietary
Vitamin K

Vitamin K
Reductase
 Vitamin K deficiency

Liver Disease or Vit. K deficiency

 Hemorrhagic disease of the newborn

 Biliary obstruction (neonatal cholestatic disorders)

 Malabsorption of vitamin K (celiac disease, ulcerative colitis)

 Drugs

 Vit.K antagonists – warfarin, phenytoin

 Broad-spectrum antibiotics – alter gut flora

 Vitamin K deficiency
 Manifestations

 Diagnosis: PT, APTT

 Management
 Vitamin K oral / sc / iv
 Repeat PT after 6hr

 Prevention
 Prophylactic Vit K to at risk population
 Coagulation Disorders: Inherited
Hemophilia A Incidence 1 in 5000 to 10,000
Hemophilia B
Factor XIII Deficiency
Prothrombin Deficiency
Factor V Deficiency
Factor VII Deficiency
Factor X Deficiency Rare
Factor XI Deficiency
Factor XII Deficiency
Prekillikrein Deficiency
High Molecular Weight Kininogen Deficiency
a2-antiplasmin Deficiency
Plasminogen Activator Inhibitor Deficiency
HEMOPHILIA

Often called ‘the disease of kings’

because it was carried by many members
of Europe’s royal family. Queen Victoria
of England was a carrier of Hemophilia
27
• X-linked recessive

• Hemophilia A (FVIII def): 80-85%

Hemophilia B (FIX def)

• Mutations of the clotting factor gene

• Family H/O bleeding common,

- generally affects males on the maternal side
- 1/3 no family history – due to new mutations
 TYPES
Disease Factor deficiency Inheritance

Hemophilia A VIII X linked recessive

Hemophilia B IX X linked recessive

Hemophilia C XI Autosomal
recessive
Parahemophilia V Autosomal
recessive
29
 Severity of Hemophilia is defined by measured
level of clotting factor activity

Distribution Clotting factor

activity
Severe hemophilia 50% <1%

Moderate hemophilia 10% 1-5%

Mild hemophilia 30-40% 5-40%

30
HEMOPHILIA
CLINICAL MANIFESTATIONS

• Bleeding can happen

anywhere
in the body.

• Following an
injury
/ surgery or
rarely
spontaneous.
32
 CLINICAL MANIFESTATIONS

Musculoskeletal bleeding
– Deep bleeding into joints and muscles
– Begin when child reaches toddler age.
– In toddlers ankle the most common

site.
– Later knees and elbow become common
sites.

33
 Hemophilic arthropathy
• Target joint
– Repeated bleeds

34
 Other manifestations
• Intracranial haemorrhage

• Hematuria

• Traumatic bleeding

• Venipuncture

35
 Hemophilia : Diagnosis
• Screening tests
– Normal PT , Raised APTT.
• Mixing studies

F VIII deficient plasma

F IX deficient plasma

• Definitive diagnosis specific factor VIII or IX by assays

Carrier state and Genetic testing

Three approaches:
1. Patient and family history

2. Coagulation-based assays: unreliable

3. DNA testing: GOLD standard

Prenatal diagnosis
37
 Case
6yr boy is brought to the OPD with
complaints of recurrent painful swelling
of the Lt Knee joint since 2yr of age. He
also has a history of prolonged bleeding
from cut sites.
O/E, Lt Knee joint swollen, tender
Investigations ???

PT- Normal, APTT – 90sec (Control – 25sec)

Mixing study: Corrected with factor IX deficient plasma
Factor VIII assay: < 1% activity

Went to a dentist for tooth extraction. Developed

uncontrolled bleeding following the procedure. How
will you manage ?
 Hemophilia: Management
Issues to be considered

• Lifestyle modifications
• Available therapeutic options
• Inhibitors complicating Hemophilia
• Prophylactic factor therapy
• Transfusion transmitted infections
 Hemophilia: Management
Lifestyle modifications: Goal - Prevention of bleeding.

- Avoid drugs that affect platelet function -NSAIDs

- paracetamol - safe for analgesia.

- Regular exercise to promote strong muscles, protect joints, and

improve fitness.
- Avoid contact sports ; swimming and cycling encouraged.

- Recognize early signs of bleeding - a tingling sensation or “aura”.

- trained to seek treatment at this stage.

- Carry identification indicating the diagnosis, severity, and contact

information .
 Hemophilia: Management

Available pharmacological agents

• Factor concentrates

• Cryoprecipitate

• Fresh Frozen Plasma and Cryo-Poor Plasma

• Adjuvant Pharmacological Options

– Desmopressin (DDAVP)
– Tranexamic acid
– Epsilon aminocaproic acid (EACA)
 Hemophilia: Management
Factor concentrates

Factor VIII Factor IX

•Half-life – approx. 8–12 hours. • About 18-24 hours.
•Each FVIII unit/ per kg i.v. will raise • Each FIX unit per kg i.v. will raise
plasma FVIII level approximately 2%. plasma FIX level approx. 0.7 to
1.0%.

•Dose of factor VIII= desired % rise x • Dose of factor IX= desired % rise x
body wt (kg) x 0.5 body wt (kg) x 1.4
 Type of Hemorrhage Desired factor level Duration (days)
(longer if indicated)
Hemophilia A Hemophilia B

Joint 10%–20% 10%–20% 1–2

Muscle (except iliopsoas) 10%–20% 10%–20% 2–3
Iliopsoas
• initial 20%–40% 15%–30% 1-2
•maintenance 10%–20% 10%–20% 3-5

CNS/head
•initial 50%–80% 50%–80% 1-3
•maintenance 30%–50% 30%–50% 4-7
WHF 20%–40% 20%–40% 8-14
Recommendations
Throat and neck
for target factor • initial 30%–50% 30%–50% 1-3
levels •maintenance 10%–20% 10%–20% 4-7

Gastrointestinal
• initial 30%–50% 30%–50% 1–3
• maintenance 10%–20% 10%–20% 4–7

Renal 20%–40% 15%–30% 3–5

Deep laceration 20%–40% 15%–30% 5-7
Surgery (major)
• Pre-op 60%–80% 50%–70%
• Post-op 30%–40% 30%–40% 1–3
20%–30% 20%–30% 4–6
10%–20% 10%–20% 7–14
 Hemophilia: Management

Cryoprecipitate
- Prepared by slow thawing of FFP at 4°C for 10–24 hours.
- Contains – FVIII, vWF, fibrinogen, & FXIII (not FIX or XI).
- supernatant - cryo-poor plasma and contains other coagulation
factors VII, IX, X, and XI.
- FVIII /bag of cryoppt is 60-100 units (avg-80 units) in a 30-40 ml
vol.
-does not contain factor IX, so no use in Haemophilia B

Concerns :
- factor content of individual packs variable.
- not subjected to viral inactivation procedures
 Hemophilia: Management
Fresh Frozen Plasma
• FFP can be used to treat both hemophilia A &B
• 1 U FFP contains about 160-250ml plasma with activity of ~80%.
• Rate and total dose limited by the risk of acute or chronic circulatory
overload.
• How to use
– Thaw.
– Transfuse over how many minutes.
– Reusing after thawing
• Disadvantages:
– No viral inactivation
– F level >20-25% difficult to achieve
 Hemophilia: Management
Desmopressin

• Only effective in mild hemophilia A - single i.v.

infusion of 0.3 mg/kg expected to boost FVIII
level 3-6 fold

• Ineffective in severe hemophilia A

• No value in hemophilia B - does not affect FIX

levels

• Nasal spray available - useful for home

treatment of minor bleeding problems.
 Hemophilia: Management
Tranexamic acid / EACA
• Antifibrinolytic agent, competitively inhibits activation of
plasminogen to plasmin.

• Valuable in controlling bleeding from mucosal surfaces (e.g.,

oral bleeding, epistaxis, menorrhagia)
- dental surgery
- eruption of teeth

• Tranexa dose for children - 25 mg/kg up to three times daily

- 500 mg tablet can be crushed, dissolved in water for
topical use on bleeding mucosal lesions.
Management of Hemophilic arthropathy
• Analgesics, ice packs ( 5 minutes on, 10 minutes
off, for as long as the joint feels hot), avoidance
of weight bearing and immobilisation.

• Factor replacement- most important

• Physiotherapy

48
 Hemophilia: Management
Inhibitors:
• Suspected - when no / inadequate response to factor
replacement.

• Detected by:
– Measuring factor levels after factor replacement
– Mixing studies

• Treatment:
– low-responders - specific factor at a much higher dose
– High responders - alternative agents like bypassing agents : as
recombinant factor VIIa and prothrombin complex
concentrates.
 Hemophilia: Management
Prophylactic Therapy
• Administration of clotting factors at regular intervals to prevent
bleeding
- Patients with clotting factor level > 1% seldom have
spontaneous bleeding

• 25-40 IU/kg of clotting factor concentrates

- 3 times/week for hemophilia A
- twice a week for hemophilia B
• Expensive but preservation of joint function & improved QOL

• Administered by subcutaneous access port of central line

 Comprehensive care
• Comprehensive team including hemophilia
specialist, nurse coordinator, social worker,
psychologist, physiotherapist, orthopaedic
surgeon, primary care physician, financial
counsellor and sometimes infectious disease
specialist

• Provided primarily through comprehensive

hemophilia treatment centres

51
 Case
6yr boy is brought to the OPD with
complaints of recurrent painful swelling
of the Lt Knee joint since 2yr of age. He
also has a history of prolonged bleeding
from cut sites.
O/E, Lt Knee joint swollen, tender
Investigations ???

PT- Normal, APTT – 90sec (Control – 25sec)

Mixing study: Corrected with factor IX deficient plasma
Factor VIII assay: < 1% activity

Went to a dentist for tooth extraction. Developed

uncontrolled bleeding following the procedure. How
will you manage ?
Classification of bleeding disorders
• Primary Hemostatic defect
– Platelet disorder
• Qualitative
• Quantitative
– Von Willebrand Disease
• Coagulation Disorders (Clotting factor deficiency)
– Acquired
– Inherited
• Vascular
Classification of bleeding disorders
• Primary Hemostatic defect
– Platelet disorder
• Qualitative
• Quantitative BERNARD- SOULIER
SYNDROME

Diagnosis
•BT
•Platelet counts
•Failure to agglutinate by Ristocetin
•PFA
•Flowcytometry
•Genetic testing
GLANZMANN’s Thrombasthenia
Classification of bleeding disorders
• Primary Hemostatic defect
– Platelet disorder
• Qualitative
• Quantitative (Thrombocytopenia)

Impaired production Increased destruction Sequestration

•Aplastic anemia •ITP
•Leukemia •SLE •Hyperspenism
•MDS •Thrombotic
•B12/Folate deficiency microangiopathy (HUS)
•Hereditary (TAR)

SPURIOUS THROMBOCYTOPENIA
 Case
2 yr girl is brought to the ER with complaints of red
colored spots over entire body for last 3 days.
H/O, URI 2wk back.
O/E, Afebrile. No Pallor
Spleen : just palpable

DDx ?
Investigations ?

Platelet count: 12000/mm3

Pathogenesis of ITP
 Definitions
Immune Thrombocytopenia (ITP)
Platelet count less than 100 × 109/L in absence of other causes or
disorders that may be associated with thrombocytopenia

• Newly diagnosed ITP: diagnosis to 3 months

• Persistent ITP: 3 to 12 months from diagnosis

• Chronic ITP: lasting for more than 12 months

Source: The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia
 Investigations

• Complete blood count

• Peripheral smear

• Bone marrow aspiration ???

Treatment of Newly diagnosed ITP
General Tt
– Education
– Activity limitation
– No NSAIDs
– Careful follow up

Observation only Vs Pharmacological Tt

 Case
2 yr girl is brought to the ER with
complaints of red colored spots over
entire body for last 3 days.
H/O, URI 2wk back.
O/E, Afebrile. No Pallor
Spleen : just palpable

Observation only

Daily follow up advised.

Comes next day with Epistaxis and gum bleeding.
What next???
Treatment of Newly diagnosed ITP
General Tt
– Education
– Activity limitation
– No NSAIDs
– Careful follow up

1st line Pharmacological Tt

• Corticosteroids
Observation only Vs • IVIG
• Anti D
1 line Medical Therapies in ITP
st

RBC

Y YAnti D

IVIG Anti D
1 line Medical Therapies in ITP
st

Corticosteroids
 2 line Treatment options
nd

• Rituximab

• High dose Dexamethasone

• Other immunosuppressants

• Splenectomy
Classification of bleeding disorders
• Primary Hemostatic defect
– Platelet disorder
• Qualitative
• Quantitative
– von Willebrand Disease
• Coagulation Disorders (Clotting factor deficiency)
– Acquired
– Inherited
• Vascular
 von Willebrand Disease
• Pathophysiology

• Types

• Manifestations

• Treatment
 DIC
Activation of
coagulation
cascade
• Causes

• Manifestations

• Diagnosis

• Treatment
Thank You